In this article we provide an evidence-based review of appendicitis, which is one of the most challenging conditions to diagnose in patients presenting with abdominal pain. Almost all clinicians are faced with the diagnostic work-up of these patients, and missing the diagnosis can result in patient decompensation. We review the literature from the initial description of McBurneys point to the clinical presentation, as well as the most appropriate imaging testing. Additionally, we review the usefulness of specific diagnostic laboratory tests. The use of computed tomography scans has reduced negative appendectomy rates when combined with a physical examination, and assists in ruling out appendicitis. Computed tomography scans with no contrast or just rectal contrast are becoming the standard in many institutions. It is essential that when the diagnosis of abdominal pain of unclear etiology is suspected, the clinicians discussion with the patient is well documented on the patients chart.
Hello my name is dr dan nedo a medical director of the health reach diabetes endocrine and nutrition center of exeter hospital in hampton new hampshire and today we’ll be talking about partnering with patients to improve therapeutic outcomes ingertin based therapy for type 2 diabetes let’s start with reviewing the actions of glucagon-like peptide 1. glp1 has the
Effect of increasing insulin secretion which helps to control postprandial glucose it also reduces glucagon release which reduces hepatic glucose production it has an effect on delaying gastric emptying and also directly reduces appetite secondary effects include increased insulin sensitivity and increased cardiovascular protection and increased cardiac output
Next let’s compare different incretin therapies the glp-1 receptor agonists and the dpp-4 inhibitors the glp-1 receptor agonists and dpv4 inhibitors both increase insulin secretion reduce glucagon secretion and tend to increase glucose uptake however only the glp-1 receptor agonists reduce food intake and reduce gastric emptying this accounts for the differences
That occur with body weight with the glp1 receptor agonists helping to promote weight loss and the dpp-4 inhibitors being weight neutral in addition both of these agents tend to reduce fasting plasma glucose and help to reduce postprandial glucose there are also differences in terms of the a1c reduction with the glp1 receptor agonists having a more robust effect
In reducing hemoglobin a1c up to 1.5 percent glp-1 receptor agonists tend to reduce body weight whereas dpp-4 inhibitors are weight neutral they are similar in terms of benefits on systolic blood pressure and lipids their safety and tolerability profile are quite different the glp-1 receptor agonists by achieving supraphysiologic levels have the risk of nausea
And diarrhea and there has been described the risk of acute pancreatitis with exenatide on the other hand dpp4 inhibitors have the potential for severe allergic reactions the glp-1 agonists are given by subcutaneous injection the lyric glue tied once daily the xenotide twice daily whereas the dpp-4 inhibitors are given orally this study compares the effect of
Long-acting insulin versus exenatide in patients on background therapy of metformin and glycemic ride and followed for 26 weeks in both groups a1c fell 1.11 percent the difference occurred in terms of body weight with xenotide patients lost 2.3 kilograms whereas with insulin glare gene they gained 1.8 kilograms a similar study with long-acting insulin versus
Lyric gluten showed that with the lyric glue tie there is a 1.81 kilogram weight loss whereas with insulin glargine there is a 1.62 kilogram weight gain effects on hemoglobin a1c were similar in the two groups limited data is available on the combined use of insulin with glp-1 analogs there is a retrospective study that suggests that when you combine xenotide
With insulin that there were modest decreases in hemoglobin a1c body weight and total daily dose of insulin compared to baseline the use of glp1 analogs with insulin is not currently approved by the fda however it is common practice that if for example a patient is on metformin plus a glp1 analog that basal insulin can be initiated at a dose of 0.1 to 0.2 units
Per kilo to target a fasting glucose under 120. this next slide compares the duration of action for the two glp-1 analogs which are currently available it can be seen that exenatide is dosed twice daily its serum concentrations rise then fall to baseline twice during the 24-hour period in comparison lyric glutine is given once daily and its serum concentrations
Are maintained for the entire 24 hour period this slide summarizes a trial which compared the effects of exeter versus lyric glutid xenotide was dosed at 10 micrograms twice daily and lyric glutine was dosed at 1.8 milligrams once daily whereas there was no significant difference in body weight by the end of the trial there was a more significant reduction in
Hemoglobin a1c with lyric glute compared to xenotide there was also a greater percentage of patients who achieved a hemoglobin a1c less than seven with lyric lutein versus xenotide looking at fasting plasma glucose there was a more profound effect with lyric glutide versus xenotide and uh in terms of insulin resistance there was a suggestion that homa b was more
Greatly improved with lyric lutein versus xenotide regarding lifestyle the introduction of glp1 analogs is a good time to introduce a healthier diet and increased activity what i often recommend to patients is that they try to increase their consumption of whole grains vegetables fruits legumes and avoid sugar white flour beef cheese and ice cream when combined
With metformin glp-1 analogs are very effective at helping to facilitate weight loss and also the combination has a very low incidence of hypoglycemia to summarize incretin therapy is a novel way to control blood glucose by regulating insulin secretion in a glucose-dependent manner glp-1 analogs are more efficacious and provide the benefit of weight loss compared
To dpp-4 inhibitors glp-1 analogs provide greater weight loss but similar efficacy compared to insulin glare gene the combination therapy of glp-1 analogs and insulin analogs may be an option for some patients greater reductions in hemoglobin a1c and fasting plasma glucose were observed with once daily liriglutide compared with twice daily xenotide lifestyle
Intervention should be initiated simultaneously with the use of glp-1 analog therapy you
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Partnering with Patients to Improve Therapeutic Outcomes By postgradmed